A Body in Motion
By Stacie Lynn Grossfeld, M.D.
Editor's Note: In this issue we welcome Dr.Stacie Grossfield, M.D., and the Body in Motion column. Dr. Grossfield is a four- time finisher of the American Birkebeiner and a fourth place finisher in the Korteloppet Cross Country Ski Marathon.
At its best; cross country skiing is a graceful, symmetric form of exercise. But when the technique isn’t quite right, or we push training sessions too hard too fast, our bodies revolt and break down. Dr. Grossfield will address the challenges faced by a body in motions and answer your questions.
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I am a 43-year-old female that skis the Birkie. This fall I started having knee pain when I was hill bounding. I now have the same type of pain with classic skiing while going up hills. I don’t remember a traumatic event or injury that started causing my pain. What do you think is causing my symptoms?
Patellofemoral pain syndrome, also known as chrondromalacia of the patella, will cause symptoms as described. This sounds like a scary diagnosis but it can actually be treated without surgery and typically without medication.
Patellofemoral pain syndrome will feel like a dull, throbbing pain as opposed to the sharp knife-like pain associated with meniscal tears. The pain is located in the front of the knee, around the kneecap, but does not typically cause swelling. Sufferers describe the pain as deep within the joint and it may be difficult to place one finger on the area that is most painful, as it often is a very diffuse pain. The knee hurts worse going up and down hills or stairs because the force on the patella is greatest in these positions. Straight-line walking, on the other hand, usually does not cause any symptoms.
Athletes that typically get patellofemoral pain fit into a specific category: they are female, under age 50, commonly have pronated (flat) feet and have a valgus alignment (knock-kneed). The combination of a structurally wide female pelvis, valgus alignment of the knees and a flat foot produces a geometry that puts a significant tug or increased abnormal force on the kneecap. This stress irritates the kneecap and the ligaments and tendons attached to it, causing the patellofemoral pain.
You can check if you have flat feet by standing in front of a mirror with your shoes off. If the inner part of the arch touches the floor or is close to the floor then the foot is pronated. A doctor, physical therapist or other foot specialist can also look at foot alignment and provide advice. However, all is not lost because of genetics; the geometry of your body can be functionally improved in several ways.
Treatment consists of placing the skier in arch supports, also called orthotics, to bring the foot out of a pronated or flat position. This, in turn, decreases the force on the patella. Place the arch supports in the shoe that you train in and your ski boots. You should wear your arch supports any time you are going to be on your feet for an extended period of time. Many people who perform daily activities that have them standing for long periods of time will wear the arch supports all day.
Arch supports can be obtained over the counter or can be custom made. The local running store often carries a variety of arch supports and should have someone knowledgeable on the staff to help fit customers with the appropriate type. Physical therapists are also a great resource for getting either pre-made or custom arch supports. Custom supports tend to be more expensive but provide a better fit. Some insurance companies will cover some, if not all, of the cost of arch supports if made by a therapist.
Another major key to pain reduction and resolution of symptoms comes from initiating a physical therapy program. The physical therapist will focus on strengthening the quad muscles around the knee, especially the vastus medialis oblique muscle (VMO), to help decrease the forces on the kneecap.
Exercises such as cycling, mini squats and leg presses will help to strengthen this muscle. Exercises to avoid, because they actually worsen the pain, are: lunges, leg extensions and deep squats. Running may also increase the pain. I would recommend alternating running and cycling during dry-land training to give the patella a rest. Alternating surfaces will also help. Try alternating running on asphalt, which is hard on the knee joint and ligaments, with running on trails or a treadmill, which have more give to them and are softer. Typically it takes four to six weeks of physical therapy or a home exercise program to significantly reduce the pain.
Over–the-counter or prescription anti-inflammatory medications do not usually help in this situation. The supplement glucosamine with chondroitin sulfate may give you some pain relief and help with the general health of your joints.
The most common diagnosis confused with patellofemoral pain is a meniscal tear. There are two menisci in the knee which act as shock absorbers between the bones in the knee joint. One is on the outer part of the knee (lateral) and one is on the inner side (medial). If a meniscus is torn, the pain pattern feels somewhat different than patellofemoral pain.
The pain from a meniscal tear tends to be localized to one specific area and the sufferer can usually point out the location of the pain with one finger. The pain is reproducible when touched and has a sharp, stabbing quality. The pain worsens with any twisting motion or deep bending of the knee. There is typically swelling of the knee joint and the sufferer can pinpoint an injury or event that precipitated the pain.
With patellofemoral pain, the sufferer cannot remember when or what started the pain. An MRI can help differentiate a meniscal tear from patellofemoral pain and dictate the course of treatment. While patellofemoral pain can be treated without surgery, a meniscal tear has to be surgically fixed with a knee scope to remove the part of meniscus that is torn.
Knee pain can be quite bothersome and limiting. It is always best to seek the opinion of a family doctor or othropaedic surgeon to help diagnose the problem and get the athlete on the road to recovery. Patellofemoral pain isn’t a season-ending injury; however, the season is much more enjoyable once the pain has resolved!